Wednesday, September 02, 2009

Divide and Conquer Is "Working"

As a result, tensions between primary care doctors and specialists might even spill over to training programs:

Tensions are rising among doctors, said Ted Epperly, 55, president of the American Academy of Family Physicians in Leawood, Kansas, in a telephone interview. Epperly runs a family practice in Boise, Idaho, and teaches at the University of Washington School of Medicine in Seattle.

Specialist colleagues have implied his support for the Medicare changes may cost his students, he said.

While family-care students typically spend parts of their three-year residencies training with specialists, “What I’ve heard is ‘maybe we just won’t have time any longer to teach your residents,’” Epperly said.

9 comments:

Keith
said...

Wes,

Looks to me like we have one big food fight to see who can sop up the most of the health care pie.

I think the trouble is all the new fangled gadgets and pills that bring little to the table, that insurers are obliged to cover even though they don't work (see vertebroplasty if you want an example). I saw a Wall Street post recently regarding Boston Scientifics' synchronous pacmaker/defib that costs 30 grand with the discussion of whether it is cost effective or not. This is all straining the abilities of busiiness and goverment to pay for all this. The high tech specialties need to stop colluding with the high ticket makers of these devices, whether they are new titanium hips or synchrounous pacemakers that offer marginal improvemetns over the old devices at significant cost. Then we can direct funds back to actual patient care and rewarding caregivers for their hard work and sacrifice.

Think comparitive effectiveness done by unbiased evaluators. Would we have spent all that money on vertebroplasties if someone had actually evaluated the results before unleasing the technique on patients? Why do we subject drugs to placebo controlled studies before release, but seemingly not medical devices? That is where all the health care dollars are getting sucked to (not to mentioned the beuracratic waste of private insurers) that leaves us fighting over the scraps.

As usual, we disagree. Your infatuation with comparative effectiveness research and the government's ability to decide what is best for my patients, has me deeply concerned.

I would like to direct you to a remarkable essay (subscription required) on this subject by Drs. Groopman and Hartzband, both on staff at Harvard Medical School, who take on this issue and thoroughly debunk many of the assumptions spewed forth in our current health care debate.

One of these is the important point that of 100 clinical studies reviewed, 23 were reversed in two years and half of former clincal recommendations were contraindicated after five and a half years.

Government czars whose primary concern is the cost to the system rather than the well-being of the individual patient will have no motivation to stay abreast of changes in clinical innovation and practice.

To continue the starry-eyed infatuation with expensive governmental agencies as the end-all to cost constraints is nothing more than a blind assumption that government knows best.

As opposed to the insurance industry that has no interest in cost and denying coverage? You have got to be kidding! I don't know about you, but it is not Medicare that I spend my day fighting with to get patients the medicines and treatments they need.

Insurance companies tend to follow the lead of Medicare anyways, which means we already have goverment beuracrats making these decisions, and I have yet to see any useful therapies denied as a result.

Our differences lie in your support for the for profit industry of medicine, whereas I think the goverment will be held in check by its citizenry from the forms of abuse you portend. You don't mess with the AARP and get re-elected in this country.

I don't think anyone would argue that if two treatments are equally effective, but one is less costly, which should be paid for by insurance and which should have the patient pay the difference out of their own pocket.

I direct you to Wendell Potters testimony before congress to get a taste of what we have currently and will continue to have with an unrestrained, profit driven health care system.

By the way, Mr. Potter, who was a VP for Cigna, has stated that the Healthcare Leadership Council, who counts your employer amongst its members, was the front group for the insurance lobby that poured enormous amounts of money into public relations to kill the Clinton health care bill in the 90s. So you are in good company and working for the right team if that is what you truly believe. My point is that all of its members Mainly for profit health care companies and big non profit hospital systems) have the high ticket administrators that make considerably more than you or I to bring us our wonderful and outrageously expensive health care system. They will continue to do all they can to keep the gravey train going and squeeze down the salaries of health care providers. After all, these CEOs and administrators are feeding at the same pig trough as you and I, and if they can eventually pay you less to fatten their pocket, so be it. Thats just capitilism!

I am curious of your opinion as to some effective efforts that would help improve the healthcare system.

For example, I have heard from some healthcare professionals that requiring ID before admitting patients in hospitals would dramatically lower costs due to treating illegal aliens. Others have pointed to HMO's and systems such as Intermountain Healthcare and The Mayo system as the ideal to better and cheaper healthcare.Even further I hear physicians and administrators argue that regulating malpractice and liability would drastically change costs and how physicians could approach treating their patients.

I would love to hear your insights as you are "the front line" of healthcare.

Whoa - one minute we're on CER, now we're on to insurers. Let's be clear what we're talking about, shall we? Look, I think you are right on the insurance issue. Face it, most of the private insurers would have likely been extinct long ago if it hadn't been for good ol' Uncle Sam taking the highest risk patients under their coffers (those over 65). I agree with you that our big insurance CEOs have no business making well over $6-20 million a year sucking our system dry. But there IS a benefit to at least being able to have SOMEONE who will respond to your calls locally. But the limited competition in our state keeps prices high for patients and limits competition betwen insurers, too - a government law. And if I really could swing it, I'd get rid of all the insurers offering $10 co-pays tomorrow and use transparency to help direct policy and clinical/treatment decisions. Yet we keep the cloud to skim the profits, right?

But government insurance isn't much better. If we give all insurance to a nationalized system, I fear about (1) the responsiveness the system will have to my needs as I advocate for my patient and (2) the costs involved. If my experience in the military is any indication, the governmental system will be glacial, expensive, and staffed by the lowest common denominators. Quantity of care will more often than not superceed quality service. With millions more needing health care and with a limited budget to do so, something's got to give. Should government tell us which is the right way to treat our patients? No. I won't go that far. Let me fight it out with you. Let's have a civil discussion and reach agreement on the right approach your our mutual patient and I bet we can reach an agreement.

Other options for "sick care" reform should be considered which have not been part of the discussion. Include a wide range of critical re-appraisals of our entire governmental and civilian health care systems. For instance, if we really wanted to cut costs, imagine the cost savings imposed by not having to staff the hospitals, police departments, administrators over government medical facilities. Has there been any realistic and thoughtful discussion of closing military and Indian reservation medical centers entirely? Subsidize our vets for free prescriptions, pay for their rehab and health care at civilian centers, etc. Why do we duplicate like we do? Is the training of military physicians really that different than Cook County in Chicago? With the exception of chemical and biologic warfare training and survival courses, I don't think so. The overhead of military hospitals far exceeds that of civilian centers on a per-patient basis from what I've seen: empty beds, overstaffing 90% of the time. Just look at Bethesda Naval Medical Center: they hold a CCU bed for the President "just in case." Please. What a waste.

And this IS our government, right NOW. Expensive, costly, and inefficient.

Look, I realize we're never going to see eye to eye on this, but I'm willing to work to find ways to keep the government from telling me how to treat my patients even WITH an 11% pay cut. But the minute a government bureaucrat screws with my patient's care and my automony to do what's right for them based on their INDIVIDUAL circumstance, that's where I draw the line.

Your last comment is very elucidating when I reconsider it. The problem seems me the problem of compartmentalizing all physician services into one bucket and attmepting to limit any increase in physician cost to the system. Meanwhile, pharmaceuticals, medical devices, insurance administrative costs, and hospital costs have been sailing skyward. All the while, we waste energy having different medical specialties fighting over the remaining crumbs with costs being shifted from one specialty to another. That was my point in my first comment that we need to stop using more expensive and unproven, or marginally more effective technology as well as getting rid of an abusive and wasteful private health insurance sytem if it increases costs. Are those synchronous pacemakers that you will be offering going to add very much to ones health at 30 grand a pop or is that Da Vinci robotic system really improving surgical outcomes? More importantly, can we really afford these marginal improvements?

All these toys we play with add additional cost to the system and result in payers looking for areas to trim costs. Since all these new innovations are generally patented, there is no other way for payers to limit their use other than to deny coverage. They have to go for savings where they can get it, which means pressuring down provider payments,whether they be hospitals or physicians.

Whereas you seem to think of comparitive effectiveness in terms of mandatory treatment guidelines, I do not see this as what comparitive effectiveness research will produce. Instead, I see it answering the questions such as is that 100 dollar a month ARB better than a generic ACE. Is angioplasty any better than medical therapy? Is that new procedure called vertebroplasty better than the old treatment of analgesics and time? Does early detection of prostate cancer with PSA really change the prognosis of this cancer? Is the use of Avastin for certain types of cancer not only life extending, but provvide any meaningful quality existence for its recipients?

Guidelines do not need to be generated out of this data, but we could instead use this to determine treatment levels of payment. You get your standard pacemenker without all the bells and whistles without any co-pay, but if you want that new asynchronous pacemaker for 30 grand, the additional cost is on your tab. If you think that 50 grand is a good price to pay for 5 months of life, then feel free to pay the tab. NO ONE IS DENYING ANYONE ANY TREATEMNT THEY WISH TO PAY FOR. JUST THE RIGHT TO HAVE INSURANCE PAY FOR IT.

By the way, CER and insurance com-panies all fall into the same pot as far as I am concerned, They all are our competitors for the health care dollar, and the items that add value should gain acceptance, but those that don't shouldn't be wating our money.

All systems have waste and you have experienced it on the goverment side, but is it not wasteful to pay your CEO 20 mil a year and what value do shareholders bring to the process when you have to pay them their divdends? Is this not waste when you are considering your end product which is health care? None of these wasteful items increases the delivery of health care! Both systems have waste; it just takes different forms. Meidcare is actually the least wasteful form of helath care delivery, so why not use it as an example. After all, no one has proposed conscripting all doctors and taking over the hospitals to work exclusively for the goverment. No where is this described in any of the proposed health care bills, although there has been a clear attempt to scare people into thinking that that this is a back door plan to a national health service.

"I have heard from some healthcare professionals that requiring ID before admitting patients in hospitals would dramatically lower costs due to treating illegal aliens.

When the rubber meets the road, doctors will care for any patient that hits the ERs of America whether they have an ID or not. It's who we are - be they illegal immigrants or not. But once their condition is stabilized, a hospital is not a place to carry out immigration policy. Until our government and society clarifies its stance on illegal immigration for business and the like, this will be a cost America will continue to absorb. Hence, while I'd like to think cost savings could occur if we just gave people ID's, I think that's a pipe dream.

Others have pointed to HMO's and systems such as Intermountain Healthcare and The Mayo system as the ideal to better and cheaper healthcare.

I'm not so sure about Mayo's cost savings. I think they're mark-up just isn't as big as other centers so they look cheap. Let me put it another way, based on a real life example. Every time my parents went to Mayo, without exception, every test they ever had locally was repeated. And every test even in the realm of possibilty for a disease was ordered. After all, Mayo has a reputation to uphold! Tests "just to be sure" seemed to be the norm. And why not? These tests dumped into their EMR and reams of paper were reliably sent back to the referring doctor. My Dad's doctor just shook his head most of the time.

Now I have no idea how much this all cost. But it's hard for me to imagine that the gold-plated center that requires much higher heating bills than most centers in the US is really all that much cheaper, especially when they test the way they do. Further, teaching centers get more money from the government and more research funds from the government. Is that cheaper to the government when those costs are included? I'm not so sure. But as long as it comes from a different pot than Medicare, well, then, it must be cheaper, right?

Even further I hear physicians and administrators argue that regulating malpractice and liability would drastically change costs and how physicians could approach treating their patients.

Now this one might have some merit. I do think defensive testing costs our system a minor fortune. But there are bad doctors out there and we must acknowledge this. I'd like to see reform that mirror's England's system where it's okay to sue, but if you lose, you pay. That seems to have the appropriate level of restraint potential built in. Another option for tort reform might include health courts, but I think getting doctors to participate would be a nightmare. Either way, I DO think reform is needed.

Sometimes the innovative "toys" that cost $30K save lives and are not just toys, but standards of care - even today. They might be that expensive because there ARE no other treatment options with the specific feature needed for the patient. Innovation is like that. I remember when catheter ablation was not approved by the government, but open heart surgery to correct an accessory pathway was. It was initially expensive to perform, but MUCH more non-invasive for the patient. If I had followed the governments' requirements, a lot more patients would have large scars in their chests. Advocating for the right treatment should supercede concerns of costs to the system, in my view. Certainly, if you want the "patient choice" option you proscribe, then cost transparency for all would be (and should be) required.

But part of the reason ICD prices have not fallen is because the government keeps paying plenty for the devices, in part, because of the device lobbyists, and in part, because hospitals want to keep making their share. The lack of transparency regarding device costs even between centers has not been insisted by the government. Why not? Because the companies, hospitals and insurers want it that way. So the trend continues.

Regarding CER, even two doctors in the same subspecialty at the same institution can disagree about the use of stents, for instance. (This is worth the 4.5 minutes to listen to the story, BTW). That's because medicine will never be a perfect science, despite what the government thinks.

Also, you say:

"Medicare is actually the least wasteful form of health care delivery, so why not use it as an example."

To which I counter: Isn't Medicare about to be insolvent soon and isn't it much of the cause of our current health care crisis? Look, I'm all for fixing Medicare first. Why aren't we doing that?

Then maybe we can talk about government running another entitlement program within budget.

As I'm not in medicine, I don't know a lot about the reimbursement schemes. However, I was under the impression that Medicare/Medicaid reimbursed a pitance and that medical practices that accepted government insurance essentially subsidized these patients with the payments made out of pocket and by private insurers. If the entire the reimbursement system followed the government model for cost savings, where would adequate reimbursement come from?

It seems to me that, if reimbursement couldn't meet payment needs, the only way to solve such a problem would be to move toward a system where health care workers are essentially salaried by the government so that nobody was dependent on reimbursement per se. Which in turn would lead to rationed care, of course...

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.